Rocking the bridge

In the mid '80s San Francisco threw a party to mark the 50th anniversary of the opening of the Golden Gate Bridge, and I was there.

When the bridge opened in the '30s it was initially closed to cars so that the citizens could stroll leisurely about, enjoying the magnificent view of the Bay, the city and the Marin Headlands. What better way, the city planners thought, to mark the 50th anniversary of the bridge than to close it to traffic and allow the citizens once again to stroll about the bridge?

It was a great idea; so great in fact that on the morning of the Great Stroll, about 500,000 people gathered at the south end of the bridge (one of which was me) and an additional 300,000 souls assembled at the north end. When the signal to let us on the bridge was given the two huge masses of humanity rushed upon it, met in the middle, and came to a complete halt. 800,000 people were on the bridge, all standing shoulder to shoulder, unable to move.

Had this happened in less civilized climes like Malaysia or New York City, it could have resulted in tragedy. Just a small group of people in a state of panic could have started a stampede that might well have resulted in thousands of deaths, people getting trampled and crushed by a human tsunami. Fortunately, the reaction of the Californian crowd to this hopeless gridlock was "Cool. Let's watch the airshow." And there we all stood for about three hours.

Two things happened on that bridge that were henceforth and evermore seared, and I mean seared into my memory. I had the misfortune to be standing near a group of Irish women who passed the time away by singing "The Hokey Pokey". It was cute to begin with, but after about an hour and a half of it my mind was filled with dark fantasies of dragging them over to the guardrails and tossing them into San Francisco bay. I have since contacted the CIA telling them that if they need a nonviolent way to extract information from a Wahabist, just lock him in a room with a group of Irish women singing "The Hokey Pokey" for hours on end. He'd sing like a canary in short order.

As we all stood in the middle of bridge without the prospect of going anywhere anytime soon, someone got the idea to see if we could get the bridge to rock from side to side. It is, after all, a suspension bridge. First a few people began to shift their weight from side to side. They were joined by hundreds more until about two or three thousand people were moving in perfect harmony, shifting the weight to the east side, then the west side, then back to the east side of the bridge.

The bridge began to move an inch or two, then several inches, and then what felt like a yard or two, swinging back and forth like a giant Foucault's pendulum. Initially the crowd was exhilarated by their power to move such a massive structure. As the bridge swayed back and forth more and more, the collective consciousness of the crowd visualized the bridge snapping in two because of the motion and the weight of the crowd, with untold thousands plunging to their death in the frigid waters of the Pacific Ocean.

"Maybe we shouldn't really be doing this", somebody called out. Proving that consensus is possible in our pluralistic society, we all instantly stopped and the bridge settled down.

This blog is a therapeutic exercise, a Primal Scream into Cyberspace if you will. But our medicolegal system is profoundly dysfunctional and needs to be rocked and shaken to its very foundations. The actions of one lonely blogger railing against the system will not change anything, though it'll help me feel better. I have very little weight to throw around these days. If someone reads this blog and is moved to express his or her own experience, and then more and more doctors take up the challenge of blogging or writing for the nonmedical community, our collective weight can rock the system and promote legal reform.

The death of one man is a tragedy; the death of a million is a statistic. If an entire hospital gets closed down for lack of liability insurance, its a statistic unless you happen to go to that hospital. If your own doctor faces a year to year difficulty with liability insurance, then it becomes a problem. If your own doctor is like a trusted friend to you, then its a crisis.

Stay with me; see the human "face" of the malpractice crisis. Don't feel sorry for me, but get angry, join me and push for reform.

Worthy of comment

I've had some feedback from my "narrative" post, ranging from "That was a good post, Dad", to "Do you know the number of the local Suicide Prevention hotline?". One very thoughtful comment read as follows:

Many patients, as your experience has taught you, confuse the circumstances of their lives, with who they are, e.g. "PWA", Person with Aids, as just one of seemingly limitless number of examples.

But physicians, too, fall into this same trap. Their monetary success, academic rank, or involvement in malpractice litigation (whether or not they were at fault) is often the fuel that fires their narcissistic awe or narcissistic rage, as the latter case may be.

This all too often leads to the problems that befalls so many physicians; substance abuse and dependency, burn-out, divorce, depression, suicide, and early death.

Reducing their view of themselves and their world to the "if only..." you can see how this happens.

Serving G-d and the community, no matter how one defines success, is usually difficult and often painful.

The advice I give to my patients, and to many physicians, is first, through self-love, find compassion for yourself, and forgive yourself. Once having done that, you can then forgive others. No longer will your rage linger and fester, as this is symptomatic of your resistance to what is.

Love and compassion.
Forgiveness and humility.
Prayer and faith.

These are the tools that made you a great doctor. They are also the tools that will enable you to find comfort.

There is of course much wisdom packed in those few short paragraphs.

One concept that has helped me to have a better understanding of virtue is Aristotle's "principle of the mean", which states that a virtue is not a polar opposite of a vice; rather, a virtue lies between the extremes of two vices. For example, courage is not just the opposite of cowardice, but occupies the middle ground between cowardice and recklessness.

Our response to adversity likewise can lie at two extremes. One is a narcissistic self-absorption, or as Frank Pittman would put it, a belief that somehow our particular brand of suffering is unique in the universe. The other is denial of pain, that ANY pain is evil and we best do all we can to avoid it. The ultimate expression of this vice is substance abuse or it's surrogates such as workaholism.

I suspect that most of us go pinging wildly back and forth between these extremes. I certainly do, although my own tendency is "extinguish the pain at all costs" which has led to my battle with workaholism.

The biggest single weakness of the blog is that it is not a very good vehicle for an extended narrative. I may spend three months and numerous posts to create a tension that finds a catharsis in the expression of pain, which then allows me to push forward and find the joy that surrounds us all if we're only attentive to it. If your first reading of my "working-through" was "A narrative", it would be easy to imagine poor me railing against the universe for having had such a bad time of it as of late.

The reality is that my suffering in the grand scheme of things is trivial. That is why I enjoy forays into "third world" countries. The folks there know what real adversity is, and they often don't even see it as anything other than life-as-usual.

On the other hand, I'd be less than honest if I said that my experiences weren't painful. Yes, we all can deny our pain, or we can savor it, but the precious middle course is to confront it, receive healing, and move on.

And that cannot happen without the input from our friends, our family, our colleagues, and from God.

A dilemma

"Do I do a quick blog, or do I run upstairs and get dressed before my wife gets back and we go to Sunday brunch?"

"Why don't you do a quick blog about the dilemma of whether you should blog or get dressed?" my son-in-law suggests.

Good point. I've got to be quick.

Lest folks wonder about what my Zoloft levels have been these days, let me share with you one of my favorite passages, written by Frank Pittman, entitled TURNING TRAGEDY INTO COMEDY:

A young man named Jeff, who was dying from cancer that had metastasized to his lungs, was a patient of mine 30 years ago. His family cried and prayed over him and pretended he would recover, though they knew he knew better. I was initially called in to relieve Jeff's pain through hypnosis. That worked fine, but he was still lying in bed out of breath, bored, angry and resentful of the fact that his life was being cut short. He demanded to know why God was punishing him in this way. His family had offered him the Book of Job, but it proved to be no help. Jeff was left wondering why God went out of his way to torment innocent people.

As Jeff and I talked about how he could use his last few weeks, the idea came up of reading a great novel about life. Jeff had been an athlete with little patience for school and he had never read a book. He chose War and Peace, the longest novel we could find, and dedicated himself to reading it, determined that he would live until he had finished it. He was a slow reader, and he lived weeks longer than anyone thought possible. He refused all pain medicine that might cloud his brain, and each day we discussed what he had read and learned about life.

Jeff's favorite scene was the one of Nicholas unhorsed and knocked out on the battlefield, coming to and noticing the cloud formations and then the cloud of dust on the horizon. As he realizes that the dust was being kicked up by French soldiers on horseback coming to kill him, Nicholas wondered, "Why would anyone want to kill me, me whom everyone has always so loved?" The wonderful absurdity of Nicholas's sunny self-satisfaction in the face of death connected Jeff to all the rest of us who will one day meet our fate. Whether we deserve it or not, whether we embrace the world or shrink from it, whether we burst with self-esteem or shrivel with self-loathing, we're all going to die.

When Jeff died peacefully the night he finished the book, he no longer felt singled out by a cruel or capricious god. Instead, he knew he was sharing the human condition, a different part of the human condition than he expected to experience at his age, but nonetheless part of what is universal for humankind.

I hope that balances my last post a bit.

A narrative

In the late 80's I found myself mired down as a semi-permanent employee of a small group practice in a small town. It was bad match from the start, and after considerable soul-searching I decided to pack up the family and move to the big city, where I would start over as a solo practitioner.

This was in the pre-Katie Couric era, when few had heard of colonoscopy and those that had heard of it believed it to be some sort of Medieval torture. Referrals were not abundant, so all gastroenterologists faced the prospect of sitting in their office, staring at the walls and wondering when the next new patient appointment would come in.

As I had neither trained nor been raised in this big city, I had no reason to believe that patients would be pounding on my door. I assumed I would starve to death and have to give my children up for adoption and put my wife to work in the local Waffle House (noble work, to be sure, but it doesn't pay all that well). Under such circumstances it is easy, instinctive really, for us to turn to God, to pray that He would "give us this day our daily bread".

I remember listening to a Chuck Swindoll sermon about faith in the marketplace. It's been a while, and I'm quoting only as best as I recall:

One business owner in our community had always put the "bottom line" ahead of ethical considerations. Although he was successful, he experienced an emptiness which no amount of money could fill. He turned his life over to God and dedicated his business to Him, vowing that from that point on he would conduct his business with the highest of ethical standards.

Not long after his conversion, he got a call.

"You've got to come quick! Your business is burning down!" he was told.

Upon arriving at his business place, he saw that indeed an uncontrollable fire had broken out and that the business he had worked so hard on in his life had just burned to the ground. His associates thought he appeared oddly unconcerned about the course of events. They asked him why.

"Well," he replied, "I dedicated this business to the Lord, and He can take it as a burnt sacrifice if He wants to."

One can debate God's role in this. Perhaps He did want the business for Himself; perhaps His only involvement was a permissive one, choosing not to strike some street thug arsonist dead for trying to impress his gang. But it made sense to the business owner. Seen through the eyes of faith and believing that God is in control and that our lives are a narrative of His action, this event would be just one more chapter of a story that will make sense in the fullness of time.

I dedicated my practice, such as it was, to God. Soon I had more work that I could handle, and financially we were secure.

During the next decade I succumbed to my workaholism. I wasn't interested in fame or fortune; I just wanted to prove to the world that this dumb old Army doc and son of a dirt-farmer could make it as a first-rate physician.

Then the lawsuits came. The first, which went to trial and in which I prevailed, left me bitter. The second, which I settled for a non-trivial amount of money in spite of some urging not to, left me defeated. The third, again settled for a non-trivial amount of money, left me crushed. I expressed to my defense attorney that maybe I should just get out of medicine. He told me, "If it makes you fell better, you're an excellent doctor whose been at the wrong place at the wrong time and has been royally "f--'d. I've never seen anything like it."

Well, it didn't make me feel better. I feel a little like the business owner looking on the burning of his business, knowing that his life will never be the same. It's not that my practice has been reduced to smoke and ashes, but it has been soaked in kerosene, waiting for the next malcontent to toss a cigarette butt on it in the form of a nuisance lawsuit.

Maybe I'd feel a little better about the whole thing if I understood what it meant. Am I being punished for the sin of workaholism (or something else? There's plenty to choose)? Am I being toughened up for some bigger challenge about to enter my life? Is it that it's simply time to move on and I'm so dense to God's guidance that He has to lead me by the nose?

My consolation is that these questions have been asked by men far better than I. Listen to the complaint of the psalmist:

Tell me, what's going on, GOD?...What am I doing in the meantime, Lord? Hoping, that's what I'm doing--hoping you'll save me from a rebel life, save me from the contempt of dunces.
I'll say no more. I'll shut my mouth, since you, Lord, are behind all this.
But I can't take it much longer...GOD, listen to to my prayer, my cry--open you ears. Don't be callous; just look at these tears of mine. I'm a stranger here. I don't know my way--a migrant like my whole family.
Give me a break, cut me some slack before it's too late and I'm out of here.

Psalm 39:4-13, taken from "The Message".

The art of being uncertain

In his latest post, Dr. John Ford, aka the California Medicine Man discusses many of the factors that go into our profligate test ordering. It boils down to the fact that we want NO uncertainly in our life, and we're willing to spend a lot of (other people's) money to rule even the most obscure possibilities.

The post is a good read and I recommend it. I've been reading a very thoughtful essay that just happened to dovetail into this discussion: Medicine, Love, and the Art of Being Uncertain by Dr. Daniel Sulmasy of Georgetown University, taken from his book The Healer's Calling, published by Paulist Press. I've enjoyed the essay and will share an extended excerpt from it:

The quest for certainty undermines trust. The quest for certainty fills the vacuum that remains as trust evaporates from the doctor-patient relationship. Intolerance for uncertainty results from the absence of a certain basic trust, informed by a strong belief that the future could not possibly turn out OK for me unless I manipulate things and people in order to make it come out OK.

Tolerance for uncertainty, by contrast, demands a level of basic trust. In the present era, however, this trust is hard to come by. It now seems as if doctors no longer trust their patients and patients no longer trust their doctors.

It is not easy to say what accounts for this situation, but I think health care professionals themselves, taken as a whole, are largely to blame. One source of this distrust and intolerance for uncertainty is that medicine has been so successful in convincing the public of its invincible powers and the certainty of a cure for everything, that death and other human limitations on medicine are now interpreted as someone's fault. This in one for the causes of the malpractice explosion and the growth of defensive medicine.

Another source of mistrust is the cynical attitude toward doctors that doctors themselves have cultivated among the public...Patients fail to see how organized medicine can claim to put patients first when organized medicine has, by and large, fought against every type of true health care reform.

Exactly.

A plug

For those of you whose interest was piqued by Dr. John Patrick's essay on the Hippocratic Oath, may I invite you to check out the Christian Medical and Dental Associations' website where there a wealth of lectures, tapes, etc. delivered by John. His talks are much more accessable than his writing, and he's a very clever and entertaining speaker to boot. He was the featured speaker on this month's "The Christian Doctor's Digest", and one who always challenges me in a most profound way.

The CMDA is one of the few organizations that are fighting for a return to the Hippocratric ideals, and are worthy of our support even if you do not consider yourself evangelical or Christian. The monthly Doctors Digest alone is worth the price of membership.

Of Cabbages and Coots

A doctor joke:

What is an alcoholic?
Someone who drinks more than his doctor.

My corollary:

When is a doctor an old coot?
When he's about ten years older than I am.

A gratuitous bonus:

In Kentucky, what is a pervert?
Someone who likes sex better than basketball.

A recent study in the Annals of Internal Medicine demonstrated an "inverse relationship between a doctor's age and his performance", which is a very graceful way of saying that the older we get, the less we stay up to date with the current trends in medicine. I don't think this is a very surprising study, and one does not have to assume that it's because we older docs have early Alzheimers and have short term memory loss.

I don't think it's because we have short term memory loss, either.

And I don't think it's because we have a short term memory loss.

OK, it wasn't that funny, but...what in the heck was I talking about?

Oh yeah. Losing one's grip as he gets older. Let's see, when I was just a mere slip of a doctor, we would treat peptic ulcer disease with heavy cream, and were thrilled when the wonder drug Tagamet was introduced. When Star Wars first hit the theaters CT scans were just entering the medical mainstream, and were greeted with the same wonderment as we had for the laser-saber. Now some radiological entrepreneurs want the CT scan to be part of the routine physical examination, like getting your blood pressure taken or your cholesterol checked.

The times, they are a-changin'.

I don't hold myself up as a model for up-to-datedness, but I'll share with you my attempts at trying to keep up with the Doogie Howsers of the world:

Harness the power of your inner geek.
Use some of your love of electronic toys for your practice. For example, I subscribe to JournalBytes that downloads medical abstracts of current interest into my handheld. I read them at my leisure and take a test on the handheld which then uploads it to their server. If I pass the test I get 3 CME credits. Epocrates and UpToDate are other fine services I subscribe to.

Let others feel your regulatory pain.
It is impossible to keep up with the literature AND take care of OSHA, CLIA, HIPAA, the CorrectCoding Initiative, Stark I & II, the Kennedy-Kassebaum Act, Medicaid utilization review, FMLA forms, Prior Authorizations for Proton Pump Inhibitors (half the population is on them), predatory insurance practices by such folks as National RedStar/RedSword, COBRA/EMTALA, endless credentialling and recredentialling, etc. etc. I'm approaching the point where the only time I'll fill out a form is when they threaten to jail me if I don't. If you don't like it, complain to the powers that be. I don't have enough resources to fight over every single PA for medications that you could get (almost) over the counter. Don't dump it on me.

Remind yourself every morning that you don't know squat.
This is particularly difficult for a gastroenterologist to admit. The longer I'm in medicine the less I feel I truly comprehend; combine that with trying to adopt a holistic approach to your practice by considering the emotional and spiritual aspects of humanity as it relates to their health, and I'm convinced that I won't ever master this noble art.

While we were passing gas...

Most colonoscopies are performed with conscious sedation, a pleasant concoction of a pain-killer and a sedative that induces a "twilight-zone" state in the patient. Once they're in that state, we can then do our examinations without causing much if any pain.

Not all patients do well with conscious sedation. Occasionally we call the anesthesiologist in to give industrial strength sedation, inducing a level of sleep that most gastroenterologists feel uncomfortable giving on their own.

During a recent case, the "gas-passer", as anesthesiologists are sometimes called, was in a fairly chatty mood.

"Doc", she said, "have you heard about that lawsuit in Arizona? Some doctor is getting sued because he didn't order a mammogram on a demented nursing home patient. But they're not suing him for malpractice. They're suing him for elder abuse!"

I hadn't heard about the case and still don't know any of the details.

"There is precedent for this kind of stuff," says I. "In California some family members wanted to destroy a physician and make a buck on it because they thought he undermedicated their dying father for pain control. California restricts non-economic losses to a mere $250,000, and of course there would be no way to generate economic losses on such a case, so they sued the doctor claiming elder abuse. The doctor was found guilty and the family was awarded $2,000,000. I doubt the jury realized that such a judgment would not be covered by malpractice insurance because it is a criminal case. The doctor was financially destroyed."

"When will this stop? When will they figure out that they've pushed too far?"

"When we all quit, which we're not likely to do because basically we enjoy the practice of medicine. Besides, we have no other marketable skills, and they know it."

So we don't worry about the simple malpractice case anymore. Instead we worry about being given a felony conviction so lawyers and families can make a buck and destroy us.

One way for us to escape this threat is simply not to see anymore Medicare patients. Because their Medicare reimbursements are slated to go down another 30% over the next few years, more and more doctors are thinking about dropping Medicare. The government has constructed huge barriers to doing this, and traditionally doctors haven't wanted to put themselves in the position where they "won't take care of Grandma".

Still, we live in a free-market society and sometimes the only thing the market understands is that a huge demand for a service or product that is in short supply will ultimately drive costs up and availability down. It seems to me that the only way things will change is when a patient calls 911 because of a medical crisis and is told that the only person they could find to man the emergency room is some third year law student.

In the meantime, I try to take solace in the words of Mother Teresa:

People are often unreasonable, illogical, and self-centered. Forgive them anyway.

If you are kind, people may accuse you of selfish ulterior motives. Be kind anyway.

If you are successful, you will win some false friends and some true enemies. Succeed anyway.

If you are honest and frank, people may cheat you. Be honest and frank anyway.

What you spend years building, someone could destroy overnight. Build anyway.

If you find serenity and happiness, they may be jealous. Be happy anyway.

The good you do today, people will often forget tomorrow. Do good anyway.

Give the world the best you have, and it may never be enough. Give the world the best you've got anyway.

You see, in the final analysis, it is between you and God. It was never between you and them anyway.

Good for another year

At home, digging through tax information that I should have staightened out a month ago, I receive a call from the office: yes, you have liablility coverage for another year, and yes, you can afford it. Cool. Year to year existence can make long term planning very difficult, but then again, none of us has guarantees about tomorrow. It's good to know that I'll have another year to generate anecdotes and vignettes for my blog.

If you don't go to other people's funerals, they won't come to yours.

Hundreds of years from now, after our race has extinguished itself in some cataclysmic paroxysm of violence and/or pure foolishness, a future race will unearth our remains and artifacts and attempt to make sense out of a hopelessly muddled and deranged civilization. (Don't you just hate tax time? It always brings out the worst in us.) When they do, I have no doubt that if they discover the sayings of Yogi Berra they will worship him and hold all that he said as sacred. His comments will have a koan-like quality, containing the paradoxes and mysteries of the universe in pithy sentences which, at least on initial inspection, seem to defy the rational process.

As Yogi said, if you want other people to come to your funeral, then you had best start going to theirs. I'd like to see a lot of people at mine, so I've been going to a lot of funerals and visitations as of late. This has included the visitation of several of my patients, a doctorly form of going down with the ship, if you will (obscure reference to the Cantatrice Chauve)

I'm no great shakes as a physician, but you'd never know it from the reception I get when I pay a visit to the grieving family. It provides me a sense of closure if I was closely involved with the patient, and the family is always touched that I would take the time to visit the funeral home.

I see aspects of the patient that I had never seen, pictures of their childhood, their confirmation, their wedding, and what they held as dear. I see them long before they started drinking too heavily, before the pancreatic cancer blossomed forth, before they experimented with drugs and contracted hepatitis C.

I become ashamed of my nominalism, my tendency to put patients and family into fore-ordained roles: "The Codependant and Somewhat Clueless Wife", "The Deeply Conflicted Son", "The Sister with Her Act Together", and "The Out-of-town Relative Whose Good Friend is A Doctor and Suggests That You're Doing It All Wrong". The roles disappear at the funeral home. They're just glad you dropped by.

If I had to do it again I would have gone to a lot more funerals in my career. I wouldn't have shied away because I didn't want to have to think about anything other than organ systems and responses to medications and coding the patient's illness correctly to insure maximum reimbursement for my efforts. Perhaps I would have seen to it that plenty of people would be on hand for my own, to see "The Doctor Who Squandered His Talents On Nonsense Instead of Involving Himself With Others". Perhaps.

A modest proposal

If given free rein, I could have the malpractice crisis pretty much straightened out in this country in about a years time. Limiting noneconomic damages is the right thing, but it is only a start.

There are better ways to deal with just compensation for injured patients than we have, and I may expound on them later. Quality control is a major issue, or as my attorney put it, "I think that knowing that you could get sued at any time makes you guys better doctors." It certainly drives up our blood pressure, increases the risk of addictive behaviors among physicians, and forces us to order lots and lots of expensive tests. It also forces physicians coming into their prime to plan an immanent retirement, either from the stress of practice or the inablility to find malpractice coverage. Whether it makes us better doctors isn't at all clear.

Nonetheless, human nature being what it is, we need a strong disincentives to laziness, sloppiness, and permanent bad judgment.

I don't think we really need to spend a lot of money on this. Most of us have lots of ego (have you ever noticed?) and we hate to be wrong, especially in front of others. Nothing would terrify me more than opening up my city's paper and seeing a lengthy article on the case that I mangled beyond recognition. That's actually one of the ways in which I was intimidated into settling. No one wants to see their shortcomings discussed on page one of the Metro section.

For the egregious blunders, I recommend the Abu Graib approach: doctors who really foul up should be made to wear underwear on their heads. Photographs would be printed on page one of the newspaper. Only the most hardcore sociopathic doctor would fail to be kept in line with this punishment lurking about them.

Then the malpractice attorneys, having nothing to do and no visible means of support, can learn useful skills such as massage therapy, dental hygiene, and life-style coaching.

Consumerism and autonomy

Dr. John Patrick is one of the finest and brightest individuals I've ever had the pleasure of meeting. These are excerpts from his paper Hippocrates and Medicine in the Third Millennium, which can be accessed by visiting his web site (I won't ever again lead you to a site where you can't get full access to the article!). He wrote this paper in the 90's although it seems as if he might have written it in the aftermath of the Terri Schiavo case.

In this narcissistic era where individual autonomy is always first it comes as a surprise to realize that patient rights have no place in Hippocrates' thinking. That, say the modern generation of bio-ethicists, is good reason to dismiss Hippocrates. But is it? Hippocrates lived in a pagan ethos where life was cheap and promises easy. His time did not have two thousand years of Christian thought anchoring it down. In such times patient autonomy was meaningless because the relationship was intrinsically unbalanced. All the power lay in the hands of the physician. The patient's safety therefore lay in the ethics of the physician. If the physician took the Oath of Hippocrates he swore to do no harm, to recognize the limits of his competence and refer appropriately, he swore to honour his profession by not abusing his opportunities for sexual gratification and he swore to treat all men equally. The patient's safety lay in doing everything to preserve the physician's integrity, to avoid even subtle coercion to kill or to abort. Remarkably there is little evidence that European culture did other than encourage physician integrity to the Oath of Hippocrates until the last century where once again rationalistic hubris began to erode this cultural gift...When one is ill, one needs someone whom one can trust to do what is best for us. No amount of verbal papering over the cracks by substituting client for patient will change the reality that sick people want someone else to handle the difficult problems. You may be a client when you choose who will fix your hernia but you are not a client when you have septicaemia and renal failure. This is where Hippocrates changed the direction of medicine. Ancient and modern pre- and post-Hippocratic physicians were and are willing to kill for a price, whether financial or ideological. There is, as Gerald Manley Hopkins put it,"a death dance in our veins"; Kevorkian illustrates this for anyone with eyes to see. Thus when you go to such physicians you must always worry whether someone else has paid more for your death than you have for your life. Those followers who took the Oath of Hippocrates removed this fear, generated a substantial trust and consequently became the physicians of choice. It was patient choice and the desire to have an income, which forced the medical profession to adopt the higher ethical standards of the Hippocratic community not the intrinsic nobility of the medical community.